Crawford Care Center: COVID Immediate Jeopardy Violations - PA
That was not an isolated breakdown at Crawford Care Center. It was the pattern.
Federal and state inspectors who arrived at the 20881 State Highway 198 facility in late July and early August 2024 found a nursing home in the middle of a COVID outbreak that staff were managing in ways that ran directly counter to Pennsylvania Department of Health guidance. By August 1, inspectors had seen enough. They declared an Immediate Jeopardy, the most serious classification available, covering all 20 residents they reviewed.
The core problem was a decision the facility had made about testing. The Infection Preventionist told inspectors on July 31 that Crawford Care Center does not test residents for COVID unless they present with a fever. The Director of Nursing and the Assistant Director of Nursing said the same thing the following afternoon: fever first, everything else second.
The Pennsylvania Department of Health guidance the facility was supposed to be following said something different. It listed eleven symptoms that should prompt testing and isolation, fever among them, but also cough, shortness of breath, fatigue, muscle aches, headache, loss of taste or smell, sore throat, congestion, nausea, vomiting, and diarrhea. The guidance noted specifically that older adults with COVID may not show fever or respiratory symptoms at all, and that any symptom on the list should trigger prompt isolation and further evaluation.
Crawford Care Center's own written COVID policy, last revised in November 2023, said the same: symptomatic residents should be tested as soon as possible and placed on transmission-based precautions while waiting for results.
The facility followed neither.
Resident R19 began experiencing lethargy, headache, nasal congestion, a sore throat, and a harsh cough on July 16. The symptoms continued through July 23. No COVID test was administered. Resident R20 developed a headache, sore throat, and cough on July 17 and remained symptomatic through July 23. Also not tested.
Resident R18 showed abnormal lung sounds and a cough starting July 25 and kept showing respiratory symptoms and lethargy in the days that followed. No test.
Resident R17 was the most acute. On July 27, inspectors found that this resident experienced lethargy, cough, cyanosis — a bluish skin discoloration indicating oxygen deprivation — wheezing, and fever. Not tested for COVID.
Two other residents were sick enough that their families requested hospital transport before the facility tested them at all. Resident R7 had difficulty breathing and lethargy on July 20 and asked to go to the hospital, where a positive test came back. Resident R11 had low oxygen saturations, was difficult to arouse, and had a productive cough on July 24; family asked that this resident be sent to the hospital, where the positive result came. By the time either was confirmed, their roommates had been living with them through those symptoms.
The roommate testing failures ran throughout the facility's records. Eight residents tested positive for COVID during the outbreak period. In case after case, their roommates were not tested, or were tested only after significant delay.
Resident R3 tested positive on July 28 with cough, lethargy, increased confusion, and nausea. The roommate, Resident R4, was not tested before being discharged to home on July 30. Resident R5 tested positive the same day with fever, cough, lethargy, nausea, and vomiting. The roommate, Resident R6, was not tested until August 1, when that resident also came back positive. Resident R15 had been showing lethargy, disorientation, and confusion since July 19; the facility sent this resident to the hospital on July 26, where COVID was diagnosed. The roommate, Resident R16, tested positive on July 28, experiencing fever, cough, lethargy, and nausea.
In one case, a roommate was tested on the same day as the positive resident and came back negative, then developed a fever, cough, lethargy, and nausea and tested negative again several days later. That resident, R14, shared a room with R13, who had tested positive on July 28 with fever, cough, lethargy, and increased confusion.
While all of this was unfolding across eight rooms, inspectors walked the halls on August 1 between 12:10 and 12:25 in the afternoon and found that COVID-positive resident rooms 201, 202, 203, 104, 110, 108, 109, and 107 had no signage on the doors indicating a respiratory infection was present inside. None of those rooms had personal protective equipment staged at the entry for staff to use before going in.
A registered nurse, identified in the inspection report as Employee E1, confirmed it when asked. Not all staff, the nurse said, wear N95 respirators when entering COVID-positive rooms. The Assistant Director of Nursing confirmed the same finding at 2:45 that afternoon.
The Pennsylvania DOH toolkit requires warning signs on every COVID room door specifying the PPE required to enter. It requires N95 respirators at minimum, along with eye protection, gowns, and gloves. Crawford Care Center's own policy listed the same equipment.
At 4:32 p.m. on August 1, the Director of Nursing and Assistant Director of Nursing were formally notified that an Immediate Jeopardy existed. They were given a template to submit a corrective action plan.
By 6:43 that evening, an acceptable plan had been approved. Signs went up on the COVID-positive rooms. PPE was staged at the doors. Roommates of all positive residents who had not yet been tested were to be tested immediately. The facility committed to moving COVID-positive residents into cohorted rooms, away from residents who had not tested positive, and to testing all residents facility-wide to understand the full scope of the outbreak. Staff on the current shift were to be educated before they went home. Staff scheduled for future shifts were to be educated before they clocked in.
The Immediate Jeopardy was removed the following afternoon.
What the inspection record does not resolve is how long the conditions had existed before inspectors arrived. Resident R19's untested symptoms began July 16. Resident R7 was sick enough to request hospital transport on July 20. Resident R15 had been symptomatic since July 19. The facility's policy of testing only for fever, its failure to post warning signs, and its failure to test exposed roommates were not practices that emerged the morning of August 1. They were in place while residents with cyanosis went untested, while sick residents rode to hospitals in search of answers, and while roommates who had slept and eaten and breathed alongside COVID-positive neighbors were sent home or left in their beds without a test.
Resident R4, the roommate of a resident who tested positive on July 28 with cough, lethargy, confusion, and nausea, was discharged to the community on July 30. Whether that resident was tested before leaving, the inspection record does not say. It says only that Resident R4 was not tested.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crawford Care Center from 2024-08-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 6, 2026 · Our methodology
CRAWFORD CARE CENTER in SAEGERTOWN, PA was cited for immediate jeopardy violations during a health inspection on August 2, 2024.
That was not an isolated breakdown at Crawford Care Center.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.